Watchdog: CMS Should Remove Quality Measures from Star Ratings Due to ‘Misinformation’

Nursing home star ratings have been under the national microscope for a good part of the spring and summer, and a health care advocacy organization joined the fray last week by suggesting that federal regulators might need to ditch the quality measure component entirely.

As currently structured, ratings on the Centers for Medicare & Medicaid Services’ (CMS) Nursing Home Compare website don’t provide an accurate picture of care quality and safety on the individual facility level, Center for Medicare Advocacy (CMA) senior policy attorney Toby Edelman wrote in a July 2 post.

“Unfortunately, the nursing home industry often uses the quality measure domain to mask poor care,” Edelman wrote, noting that some operators will point to high quality scores when stories of deficiencies and other issues break in the media.


First launched in December 2008, Nursing Home Compare provides skilled nursing residents and their families with information about an individual building’s quality, staffing, and health inspection performance. A SNF receives a rating of one out of five stars for each of the three domains, which are then averaged into an overall star rating.

CMS has tweaked the program several times in its decade of operation, but a 2018 shift from self-reported to payroll-based staffing data caused controversy when the New York Times revealed that some operators had been reporting higher-than-actual nursing and caregiver coverage under the old system.

The government responded quickly, slapping nearly 1,400 facilities with an automatic one-star staffing rating last summer. CMS then updated its standards for the overall five-star system this past winter, introducing stricter staffing standards and providing separate ratings for short- and long-term stays.


“Nurse staffing has the greatest impact on the quality of care nursing homes deliver, which is why CMS analyzed the relationship between staffing levels and outcomes,” the agency said when announcing the changes in March; they later took effect April 24. “CMS found that as staffing levels increase, quality increases.”

But the changes weren’t enough to prevent another round of media attention to Nursing Home Compare: A bipartisan duo of U.S. senators in June released a previously internal list of 435 properties considered for inclusion in the Special Focus Facilities program, CMS’s designation for 88 properties considered most in need of improvement.

While CMS hides the star ratings of the 88 actual Special Focus Facilities, information about the candidates remains publicly available, with Sens. Bob Casey and Pat Toomey — both of Pennsylvania — noting that nearly half of the buildings considered for the SFF roster had staffing or quality ratings of three stars or more.

“As evidenced by this report, oversight of America’s poorest quality nursing homes falls short of what taxpayers should expect,” the senators wrote.

CMS again took swift action, promising to publicly update the candidates’ list on a monthly basis while also emphasizing the government’s efforts to effectively regulate the nation’s nursing homes.

“This is greater oversight than for any other setting of care,” CMS chief medical officer Kate Goodrich said of her agency’s focus on skilled nursing facilities.

But while Edelman praised CMS for hiding ratings for Special Focus Facilities in her post for the CMA, she remained concerned about providers’ ability to point to solid quality ratings in the face of other issues.

“CMS should not allow nursing homes to mislead consumers about nursing home quality in this way,” Edelman wrote.

In Edelman’s view, CMS has one of three options. Officials could rename the quality domain as “resident assessment data,” thus clarifying that the information comes from self-reported sources, decline to award a star rating for the quality category, or simply remove the quality measures from Nursing Home Compare entirely.

“CMS’s implicit recognition of the misinformation contained in quality measures for Special Focus Facilities is a good first step, but CMS could do more to protect all nursing home residents and families,” she concluded.

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